The training and assessment system was ineffective, in this case, because it placed an individual with deficiencies in scanning and conflict resolution in a control position.
The safety information provided to passengers did not adequately explain that oxygen will flow to the masks without the reservoir bag inflating.
Cabin crew training facilities did not appropriately replicate the equipment installed within the aircraft, including the drop-down oxygen mask assemblies.
The operator's cabin emergency procedures did not include specific crew actions to be carried out in the event of a PATR failure.
Some cabin crew-members did not have an appropriate understanding of the oxygen mask flow indication system.
While maintaining the appropriate general quality accreditation (ISO 9001) of its engineering facilities, the operator did not maintain independent accreditation of the specific procedures and facilities used for the inspection, maintenance and re-certification of oxygen cylinders.
Some cabin crew-members did not have an appropriate understanding of the aircraft's emergency descent profile, leading to misapprehensions regarding the significance of the situation.
The tower was not assembled as designed. The outriggers and intermediate planks, both key components, were missing and the work platform guard rails were not used. The manufacturer’s instructions were also missing but no attempt was made to obtain them, a parts list or the missing parts.
United Treasure’s permit to work aloft system had not been effectively implemented on board the ship. In addition, the standard form for the permit did not ensure that the officer in charge of the work and its authoriser were not the same person and that a risk assessment was formally undertaken by at least two responsible officers.
While enclosed space entry checklists were being filled out by the crew members on board Bow De Jin, the checklist system was not being used as a proactive means to ensure that the necessary safety requirements were being met prior to tank entries.
Following the separation of the IP turbine disc from the drive arm, the engine behaved in a manner that differed from the engine manufacturer’s modelling and experience with other engines in the Trent family, with the result that the IP turbine disc accelerated to a rotational speed in excess of its design capacity whereupon it burst in a hazardous manner.
The absence of an altitude deviation alert within the Australian Defence Air Traffic System increases the risk of undetected altitude variation and contributed to the significant loss of altitude.
Interruption of electrical power to the multi purpose flight recorder due to water ingress removed of an important source of information used to identify safety issues.
The design and relative positioning of the external air vent and avionics modules permitted the ingress of moisture and particulates that led to corrosion and contamination of electronic avionics components and consequently the generation of multiple erroneous crew alerting system (CAS) messages due to electrical shorting.
The lack of formalised procedures in place requiring the Air Crew Officer (ACO) to monitor key instrument indications probably contributed to the undetected altitude loss.
In this instance, the consensus of the regulatory authorities is that Karratha Spirit was not in a navigable form at the time of the accident and was therefore under NOPSA’s jurisdiction according to the OPGGSA. However, the point at which Karratha Spirit became ‘navigable’ is not clearly defined in the OPGGSA and is open to interpretation.
The procedures for connecting and disconnecting the import hose and disconnecting from the CALM buoy in place on board Karratha Spirit were signed off as being satisfactory and reflecting shipboard practice, but they had not been effectively reviewed on board the ship. Consequently, the ambiguities in the procedures and the discrepancies between the procedures and the ship’s practices were not identified during any shipboard review or audit and were not made known to the ship’s managers through any review process.
